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i APPLICATION FOR SANITATION PERMIT Permit No. ------- --- tpplicat�ion (Complete in Duplicate) Date issued is hereby made to the San Joaquin Local Health District for a permit to construct and instal the wgrk herein described.r This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION_ Il-----i -- - -- --'- ---- -----=-------- ' r .Owner's Name-------�Wr ---------------------------------------------------------------------------- Phone-------------------- -------------------------- ---------- 7 Contractor's Name---------- - ----------- ------------------- Phone--------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -.-�_____ Number of bedrooms Number of baths j---- Lot size -___�-/- - - --��- � - ---------------- - Water Supply: Public system El Community system -E] Private Depth to Water Table .-�?--- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ' Hardpan p Previous Application Made: Yes ❑ No -..,New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if publ�;"serer,is available within 200 feet.) Septic Tank: Distance from nearest well-----_c5_0__Distance from-Nun on----- ----__.Materia ------ o-_?t �Vt --- No. of compartments-----------;'�------Size__�s�._ ----__�---Liquid depth___________-_---_-_-___Capac _"___ x 1 Disposal Field: Distance from nearest well__: ___.Distance from foun tion_____ ____:Distance to nearest lot lin /i. d_ Number of lines-------- -- Length of each linq__ _ ______`___.Width of trench________j __- _ Type of filter material___ __�__ epth of, filter material------- ---------Total length------- Q____________-_____ Seepage Pit: Distance to nearest well_--------------------Distance from foundation--------------------Distance to nearest lot line___________._____ ❑ Number of pits---------------'-----Lining material Size: Diameter-----------------------Dep+h--------------------------------- Cesspool: Distance from nearest well______________""_Distance from foundation-------------------Lining material____--__________________________-- -- ❑ Size: Diameter_---- --------- Depth - --- - "---------- ----- ----Liquid Capacity- ..--------------------------gals. egl �_; -;.; Y " `"""" �" Distance from nearest buildin Priv : Distance from nearest well_____- --__-__ _____ __ --- ------- cJ--------- ---------- - -- ❑ Distance to nearest lot'line----------- ------- -- ------ , ---- - --------------------------------------------------------------- ..----------------- 6 0 Remodelinrg;,and/or repairing,(describe f _ - ---------- -iA--- --------- ---- ---- ___ ________"___-____--________________- __----_____"_- __________________________________________________________________________.___ ________ ______________________ ____________ hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)------- -•--��-��---------- ---- --- ----- - ------ -----------=-----------"-- - ------------------ -------___________________________{Owner and/or Contractor) By41 ------------------------------------------------------------------------------------------ (Title)------------------------------------ --------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY - - APPLICATIONACCEPTED BY-------------- ------ ----------------------------------------------------------- DATE------------------------------------------------------------ ` '-------- REVIEWED BY------------------------ ------------ -- _ - DATE '�: BUILDINGPERMIT ISSUED----------------------- __ -.�-- _----------- ----------- DATE--------------------------------------------- ----- -------- - "=�- ----------------- Alterations and/or recommendations:------- ------------------- -----"--------------------------------------------------.---------------------------------- - --- ------------- -- -------------------------------------------------------- -------------- y -------------------------- ---"------------------------------------------- - ------------------------------------------------- --- - - ------- ----- ------------ - -- -------- - -- -------------- --------------------- ------ ----------------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY------------ ______________ ------------------------------------- Date-----"------ - -----------------------------. SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 8-51 Revised W-2100